Balloon enteroscopy can be performed to reach through the Roux limb, via the entero-entero anastomosis, and further on through the biliary limb into the duodenum to find the papilla.

Balloon enteroscopy has been available since the beginning of 2000, first described by Yamamoto [1]. There are two current technical solutions: the double-balloon technique from Fujinon and the single-balloon technique from Olympus. Both require specialised equipment and expertise that are not widely available. A long Roux limb can be technically challenging as well as the different anatomic constructions of the entero-entero anastomosis, both varying with type of reconstruction (Fig. 10.2). One major problem with balloon enteroscopy ERCP is the lack of efficient accessories. The enteroscope is long, 2 m, and the working channel is only 2.8 mm, making it impossible to use standard ERCP accessories. There are only a few specialised accessories for these procedures on the market, and some are not possible to use over a guidewire. Another drawback is the lack of elevator at the tip of the endoscope and the fact that the papilla is reached and visualised from below. All these factors make both cannulation and therapy challenging. A cap on the tip of the endoscope has been proposed to fixate the papilla during cannulation, making the procedure easier.

In a recent review article by Inamdar, the success rates for reaching the papilla in patients with altered anatomy differed between 55 and 100% [2]. The pooled enteroscopy success rate for all kinds of altered anatomy was 81% (CI 75–86%). The major reason for failure was difficulty to identify the biliary limb at the entero-entero anastomosis or trouble with intubating this limb with its marked angulation. The pooled diagnostic success rate for all attempted enteroscopies was 69% (CI 61–78%), and the pooled success rate for completed interventions was 62% (CI 53–71%). In patients with a successful enteroscopy, reaching the duodenum, the rate for interventional success was 79%. Schreiner et al. suggest that a successful balloon enteroscopy-aided ERCP is less likely in RYGBP patients with an alimentary limb of more than 150 cm [3].

The percutaneous transhepatic cholangiography (PTC) technique has been used for many years for diagnostic and interventional purposes in the biliary tree. Direct transhepatic cholangioscopy, utilising the PTC access for endoscopy, was first described in 1974 by Takada. Today the PTC technique is often used as an alternative to ERCP for internal or external drainage of the biliary tree in situations with difficult cannulation. This access route can be used for interventions similar to those carried out using standard ERCP techniques. In patients with altered anatomy, the PTC technique offers an access route into the biliary system possible to use for primary interventions, for direct cholangioscopy and for aiding in enteral endoscopic interventions with rendezvous technique.

We have used this technique for rendezvous procedures aiming at ERCP in patients with altered anatomy. A guidewire was introduced through the PTC catheter through the papilla and advanced down to the entero-entero anastomosis to meet a balloon enteroscope. The guidewire was grasped by a snare from the endoscope which then could be manipulated up to the papilla (Fig. 10.3). Biliary interventions were then performed over the existing guidewire. Different endoscopes can be used for these rendezvous interventions, depending on the length of the Roux limb (in gastric bypass – enteroscope, after Whipple procedure or total gastrectomy – therapeutic gastroscope).

In gastric bypass patients, a gastrostomy placed in the remnant stomach can be used as an access port for ERCP (Fig. 10.4). The gastrostomy can be achieved using various techniques: